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� 6 0" <br />STATE OF CALIFORNIA • A <br />STATE WATER RESOURCES CONTROL BOARD 3 <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :� 2° <br />Zz <br />1/ COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY E:1 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F—] 7 PERMANENTLY CLOSED SITE <br />ONE ITEM J 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE o <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA R FA ILITY+IN E <br />DAYS: NAME (LAST, FIRST) <br />PHONE 8 WITH AREA <br />NAMEOF OPERATOR <br />NIGHTS: NAME (LAST, FIRST) <br />✓ box to indicate INDIVIDUAL <br />PHONE 4r WITH AREA CODE <br />TION L <br />STA E <br />ZIP CODE HON #WITH AREA CODE . <br />ADDDRRES <br />� z/ <br />NEAREST CROSS STREET <br />PARCEL # (OPTIONAL) <br />CITY NAME <br />641MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />1=0RM A (12 91) FILE THIS <br />STATE <br />ZIP CODE <br />ITE PHONE # WITH AREA CODE <br />I <br />`o�L <br />a <br />&3 <br />CA <br />o�� <br />-- ✓ BOX <br />TO INDICATE <br />CORPORATION INDIVIDUAL 0 PARTNERSHIP <br />LOCAL -AGENCY 0 COUNTY -AGENCY <br />Ej] STATE -AGENCY 0 FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS <br />C� I GAS STATION 0 2 DISTRIBUTOR <br />IF INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />RESV ERVATION <br />3 FARM 4 PROCESSOR Lj <br />5 OTHER <br />OR TRUST LANDS <br />3 <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) P ONE # ITH AREA CODE <br />1_7%til - —� T — <br />DAYS: NAME (LAST, FIRST) <br />PHONE 8 WITH AREA <br />NIGHTS: NAME (LAST, FIRST) NONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />✓ box to indicate INDIVIDUAL <br />PHONE 4r WITH AREA CODE <br />It. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />/3�i�ac✓ z0--rG Go . <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box Ioindicate 0 INDIVIDUAL 0 LOCAL -AGENCY STATE -AGENCY <br />✓ box to indicate INDIVIDUAL <br />.ARPORATION 0 PARTNERSHIP 000UNTY-AGENCY FEDERAL -AGENCY <br />TION L <br />STA E <br />ZIP CODE HON #WITH AREA CODE . <br />CITWNE �D <br />STATS <br />� z/ <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAAE OF OWNER <br />CARE OF ADDRESS INFORMATION <br />JURISDICTION # FACILITY # <br />� a <br />MAILING OR STREET ADDRESS <br />✓ box to indicate INDIVIDUAL <br />OLOCAL-AGENCY STATE -AGENCY <br />TION L <br />CORPORATION 0 PARTNERSHIP <br />COUNTY -AGENCY FEDERAL -AGENCY <br />CITWNE �D <br />STATS <br />ZIP CODE# <br />PHON�WS REA CO <br />if <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />TY (TK) HQ 4 14_Ion- D <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to indicate <br />I SELF-INSURED E:1 2 GUARANTEE L__1 3 INSURANCE 4 SURETY BOND <br />5 LETTER OF CREDIT = 6 EXEMPTION F7 99 OTHER <br />VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. = II. III. ❑ <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANT'S NAME (PRINTED & SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # <br />3 <br />JURISDICTION # FACILITY # <br />� a <br />� <br />LO©TJQN CODE OPTIONAL <br />CENSUTRACT # - <br />TION L <br />SDISTRICT CODE -OPTIONAL .&C <br />THIS FORM MUST BE ACCOMPANIED BY AT LEIST (1) <br />641MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />1=0RM A (12 91) FILE THIS <br />FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />0 <br />a <br />&3 <br />